The Role of PKG in Parkinson’s disease
I already know how to manage people with Parkinson’s…why do I need a PKG?
Parkinson’s symptoms are frequently varying over time and difficult for patients to identify and report on. The PKG supports your clinical evaluation by adding tangible, objective data obtained over an entire week as your patient goes about their routine activities to evaluate their motor symptoms and aid in your clinical decision-making.
How can objective measures like PKG enhance my ability to treat Parkinson’s disease?
The PKG provides clinically meaningful, timely and accurate objective measurement of symptoms in relation to medication timing, sleep and exercise that can enhance clinical decision making and help improve patient outcomes.
What types of patients would be most suitable for PKG?
Any patient can benefit from PKG. Examples include:
- Patients who have PD for >3 years and/or are needing >3 doses of L-dopa per day
- New referrals
- Remote patients
- Those experiencing possible fluctuations
- Patients experiencing unidentified symptoms
- Patients who have difficulty communicating their symptoms
- When medications are being initiated or changed
- Patients being considered for device assisted therapies.
Are there patients who will not benefit from PKG?
While the PKG helps inform clinical decision making for many features of PD, there are some motor features that we are working to better characterize – these include gait freezing and imbalance.
Ordering a PKG
How do I start using PKG in my clinic?
Do I need special equipment to use PKG?
You simply need access to a computer connected to the internet. Global Kinetics will provide you with any additional equipment.
What instructions should I provide to my patient receiving a PKG?
Global Kinetics will provide you with training on what information you should share with your patients, along with a brochure with instructions on how to use the PKG, for your patient to use at home.
Can I order a PKG for a patient in a different time zone?
Yes, the watch time zone can be selected when setting up a patient profile.
Does the patient need to charge their PKG watch?
No, if the session is started within three days of configuration, the battery will last for at least the 7-day recording.
What is the cost of PKG?
Who should I contact if I have further questions about ordering PKG?
If you need assistance using the PKG system, please contact your local Global Kinetics representative or send an email to our Technical Support team. Include your name, clinic and contact details. For patient privacy, please do not include patient details.
Interpreting a PKG
My patient has completed their PKG wear…how do I see the results?
After the patient has worn the watch, the data will be uploaded to the PKG Portal that can be accessed in this secure online portal.
Where can I go to learn how to interpret the PKG report?
Global Kinetics provides training on the principles of PKG and on PKG report interpretation.
My patient is “out of target”…what does that mean?
The use of the PKG provides a new and exciting model of care for managing the symptoms of Parkinson’s. Unlike rating scales or other technologies that provide you a relative indication of whether a patient is doing better or worse, the PKG scores compare how your patient is doing relative to a large group of age-matched individuals without Parkinson’s. This standard comparison group is used as the basis for setting the ‘Target’ for various scores and provides an absolute number to assess whether your patient has well controlled symptoms (relative to the standard group), and how their own symptoms change over time (comparing patients to themselves).
For more information on the basis for PKG Targets, see below:
Farzanehfar P, Woodrow H, Braybrook M, McGregor S, Evans A, Nicklason F, Horne M. Objective measurement in routine care of people with Parkinson’s disease improves outcomes. NPJ Parkinsons Dis. 2018 Apr 3;4:10. https://www.nature.com/articles/s41531-018-0046-4.
The PKG report shows that the patient is “immobile”…what are the possible clinical explanations for this?
High immobility scores on the PKG can represent a variety of possible states, including: sleep, inadequately treated symptoms (e.g. ‘severe off’ or ‘gait freezing’), or a sedentary lifestyle. Exercise is known to be and important aspect of Parkinson’s management. Recognition of immobility allows the Clinician to identify and treat the underlying cause.
Are there certain artifacts on a PKG report that I should be aware of?
Yes, there are certain movements that may mimic features of Parkinson’s. Completing the PKG training program will help you to recognize and differentiate these artifacts. One such example is the act of brushing teeth can mimic the appearance of dyskinesia. A trained PKG user will be able to differentiate between these two states.
I have a PKG report that I’m not sure how to interpret…is there some place I can ask for help?
Yes, you can contact the technical support team.
If you need assistance using the PKG system, please contact your local GKC representative or send an email to our Technical Support team. Include your name, clinic and contact details. For patient privacy, please do not include patient details.
Using the PKG to Guide Management
The PKG report shows that my patient has a high bradykinesia score (BKS)…what should I do?
The management of Parkinson’s requires a deep understanding of the patient and their symptoms, with no one solution that will solve every patient’s needs. We recommend that the PKG information be used to inform the clinician’s view of the patient’s condition and make recommendations based on their understanding of the individual patient. A high BKS represents symptoms of bradykinesia that are out of ‘Target’ and would generally benefit from additional treatment based on peer-reviewed publications. With this information in mind, it is up to the clinician to decide the appropriate therapeutic strategy to pursue.
Are there management algorithms that I can use based on the PKG?
No current algorithm exists to provide management recommendations based on the PKG. As more patients and clinicians use objective measures such as the PKG, we will learn whether such algorithms can be developed.
Can the PKG help me identify patients needing advanced therapies such as deep brain stimulation or levodopa infusion?
The hallmarks of a patient that may benefit from advanced therapies are severe dyskinesia and on-off fluctuations. The PKG is able to objectively and reliably identify both of these disabling features.
Can my RPM interaction be combined with a regular office visit (E&M Visit) or does it need to be a separate interaction?
Your RPM interaction cannot be combined with a regular office visit (E&M Visit) or billed on the same day as an E&M visit. Time for your RPM interaction must be a specific and separate interaction and billed separately.
What is an RPM interaction? What types of tasks/interactions are considered billable moments under RPM?
Any time spent that is associated with care management for your patient is considered a billable moment with RPM codes. In order to bill CPT 99457, there must be a synchronous, interactive communication with the patient/caregiver from a physician/clinical staff or other qualified health care professional during the 30-day period of the monitoring.
Examples using PKG for RPM:
- Entering PKG order into the Portal
- Downloading PKG Report & Uploading the PKG to EMR
- Reviewing and Interpreting PKG Report
- Discussing PKG Findings with Patient
Is RPM time cumulative or does each 20-minute code (99457 and 99458) require a separate interaction with the patient?
CPT codes 99457 and 99458 are used to report treatment management of a patient currently monitored remotely for physiological parameters. Report 99457 once per calendar month when at least 20 minutes of care management and communication is provided, regardless of the number of modalities performed. Report 99458 for each additional 20 minutes minimum of care management and communication during the same month.
The RPM time is the cumulative time spent tending to RPM tasks, including the patient interaction. The time should be compiled, documented and billed accordingly for each 30-day period. You must reach the respective time checks (20 minutes/40 minutes, etc.) to be eligible to bill the RPM time specific codes.
How do I track/itemize my time with RPM? How detailed do I need to be in my notes to protect myself in the event of an audit?
Practices should retain a detailed record showing itemized time spent in care management and communication for each patient. PKG Reports should be included in documentation as additional support for the use of the PKG Watch, transmission and analysis of the PKG data.
How much are the potential out of pocket costs for my patient pay per month or for the term of the RPM program?
Potential out of pocket cost is dependent on each patient’s unique situation and insurance providers. Please check with the primary and secondary insurance providers to find out their specific coverage policies related to RPM.
Is PKG data transmitted and stored securely?
Can patients receive a copy of their PKG report?
The PKG report is provided to the ordering clinician. It is up to the clinician to develop a policy on how best to share the PKG results.
Indications for use
The Personal Kinetigraph (PKG) System is intended to quantify kinematics of movement disorder symptoms in conditions such as Parkinson’s disease, including tremor, bradykinesia and dyskinesia. It includes a medication reminder, an event marker and is intended to monitor activity associated with movement during sleep. The device is indicated for use in individuals 46 to 83 years of age.